Spinal Hypermobility: Understanding, Causes, Symptoms, and Management

What is Spinal Hypermobility?

Spinal hypermobility refers to an excessive range of motion or laxity within one or more segments of the vertebral column, meaning the joints of the spine move beyond their typical physiological limits.

Understanding Spinal Hypermobility

Joint hypermobility, often colloquially referred to as "double-jointedness," describes the ability of a joint to move beyond its normal range of motion. When this characteristic specifically affects the spine, it is termed spinal hypermobility. This condition can manifest in any region of the spine—cervical (neck), thoracic (mid-back), or lumbar (lower back)—and may be localized to a single segment or be part of a more generalized joint hypermobility syndrome affecting multiple joints throughout the body.

Unlike flexibility, which is the ability of a muscle to lengthen, hypermobility relates to the laxity of the ligaments and joint capsules that provide passive stability to the skeletal system. While some degree of flexibility is desirable, excessive hypermobility in the spine can compromise its inherent stability, potentially leading to pain, dysfunction, and increased risk of injury.

Anatomy and Biomechanics of Spinal Stability

To appreciate the implications of spinal hypermobility, it's crucial to understand the intricate system that provides stability to the spine. This system is often conceptualized as comprising three interacting subsystems:

• The Passive Subsystem: This includes the vertebrae (bones), intervertebral discs, ligaments, and joint capsules. These structures provide inherent stability by limiting excessive movement.
• The Active Subsystem: Composed of the muscles surrounding the spine, this subsystem is further divided into:
  • Local Stabilizers: Deep muscles like the transverse abdominis and multifidus, which provide segmental control and stiffness.
  • Global Movers: Larger, superficial muscles that generate movement and provide broader stability.
• The Neural Control Subsystem: This is the "brain" of the stability system, integrating sensory information from the passive and active subsystems to coordinate muscle activity and maintain posture and movement control.

In spinal hypermobility, the passive subsystem, particularly the ligaments, may be excessively lax. This puts increased demand on the active and neural control subsystems to compensate for the lack of passive stability, potentially leading to muscle fatigue, spasm, and impaired motor control.

Causes and Contributing Factors

Spinal hypermobility can arise from a combination of genetic, structural, and acquired factors:

• Genetic Predisposition: Many cases are hereditary. Certain genetic connective tissue disorders, such as Ehlers-Danlos Syndrome (EDS) and Marfan Syndrome, are characterized by widespread collagen abnormalities that result in hypermobile joints, including the spine.
• Ligamentous Laxity: Individuals may naturally have "looser" ligaments due to their genetic makeup, even without a formal diagnosis of a connective tissue disorder.
• Trauma or Injury: Accidents, falls, or repetitive microtrauma can stretch or damage spinal ligaments, leading to localized hypermobility.
• Degenerative Changes: Paradoxically, advanced degenerative disc disease or facet joint osteoarthritis can sometimes lead to segmental instability and hypermobility, particularly in the early stages before significant bony changes occur.
• Muscle Weakness or Imbalance: Insufficient strength or poor coordination of the core stabilizing muscles can fail to adequately support the spine, allowing for excessive movement even if ligaments are structurally sound.
• Postural Habits: Prolonged poor posture or repetitive movements can stress spinal segments, potentially leading to localized laxity over time.
• Over-Stretching or Unsupervised Flexibility Training: While flexibility is beneficial, aggressive or uncontrolled stretching, particularly into end-range movements, can overstretch ligaments and contribute to hypermobility.

Common Symptoms and Clinical Presentation

The symptoms of spinal hypermobility vary widely, from asymptomatic to severe, debilitating pain. Common presentations include:

• Pain: Often the primary symptom, ranging from dull aches to sharp, intermittent pain. It can be localized to a specific spinal segment or radiate if nerves are irritated. Pain is frequently worse with sustained postures, certain movements, or activity.
• Sensation of Instability: Patients may describe their spine "giving way," "slipping," or feeling "unstable," sometimes accompanied by clicking, clunking, or grinding sounds.
• Fatigue: Muscles work harder to stabilize the hypermobile segments, leading to chronic muscle fatigue, especially in the back and neck.
• Muscle Spasm and Stiffness: As a compensatory mechanism, surrounding muscles may go into spasm to guard and protect the hypermobile segment, leading to feelings of stiffness despite underlying laxity.
• Proprioceptive Deficits: Reduced awareness of body position in space due to altered joint feedback, potentially leading to clumsiness or poor movement control.
• Neurological Symptoms: In severe cases, excessive movement can irritate or compress spinal nerves, leading to radicular pain (e.g., sciatica), numbness, tingling, or weakness in the limbs.

Diagnosis and Assessment

Diagnosing spinal hypermobility requires a thorough clinical assessment by a healthcare professional, such as a physical therapist, chiropractor, or physician specializing in musculoskeletal conditions.

• Clinical History: Detailed questioning about symptoms, pain patterns, aggravating and relieving factors, and family history of hypermobility or connective tissue disorders.
• Physical Examination:
  • Observation: Assessing posture, spinal curves, and movement patterns.
  • Palpation: Feeling for muscle tension, tenderness, and joint alignment.
  • Range of Motion Assessment: Evaluating active and passive spinal movements.
  • Special Tests: Specific orthopedic tests to assess segmental stability and rule out other conditions.
  • Beighton Score: While primarily used to assess generalized joint hypermobility, a high Beighton score can indicate a predisposition to spinal hypermobility.
• Imaging Studies:
  • X-rays: Dynamic flexion and extension X-rays can sometimes reveal excessive translational or angular movement between vertebrae, indicating instability.
  • MRI (Magnetic Resonance Imaging): While not directly showing hypermobility, MRI can rule out other structural pathologies like disc herniation, spinal stenosis, or fractures that may cause similar symptoms.

Implications and Risks

Unmanaged spinal hypermobility can lead to several adverse outcomes:

• Chronic Pain Syndromes: Persistent back or neck pain is common due to ongoing stress on spinal structures.
• Increased Risk of Injury: Hypermobile segments are more susceptible to sprains, strains, and intervertebral disc injuries (e.g., herniation).
• Spondylolisthesis: In some cases, chronic instability can lead to one vertebra slipping forward over another.
• Functional Limitations: Difficulty performing daily activities, exercise, or work tasks due to pain, instability, or fear of movement.
• Compensatory Muscle Patterns: Over-reliance on global muscles can lead to fatigue and inefficient movement.
• Psychological Impact: Chronic pain and physical limitations can contribute to anxiety, depression, and kinesiophobia (fear of movement).

Management and Exercise Considerations

The primary goal of managing spinal hypermobility is not to increase flexibility, but to enhance stability and control of the spinal segments. This often involves a comprehensive, individualized approach:

• Strengthening and Motor Control Training:
  • Core Stability: Emphasize training the deep core muscles (transverse abdominis, multifidus, pelvic floor) to provide segmental stiffness.
  • Proprioceptive Training: Exercises to improve body awareness and neuromuscular control, often using unstable surfaces or balance challenges.
  • Global Muscle Strengthening: Build strength in the glutes, hips, and other large muscle groups to support overall spinal mechanics.
• Avoidance of End-Range Stretching: Individuals with spinal hypermobility should generally avoid aggressive or prolonged stretching into end-range spinal flexion, extension, or rotation, as this can further stress already lax ligaments. Emphasis should be on strengthening through mid-range movements.
• Postural Education: Learning and practicing optimal spinal alignment during daily activities, sitting, standing, and lifting.
• Movement Re-education: Training efficient and controlled movement patterns to reduce stress on hypermobile segments.
• Pain Management: May include manual therapy (gentle mobilization, massage, but often avoiding high-velocity thrusts), modalities (heat, ice), and pain relief medication as needed.
• Activity Modification: Identifying and modifying activities that aggravate symptoms.
• Education: Understanding the condition empowers individuals to manage it effectively and make informed choices about their physical activity.
• Multidisciplinary Approach: Collaboration between physical therapists, exercise physiologists, orthopedic specialists, and other healthcare providers is often beneficial.

Conclusion

Spinal hypermobility is a complex condition characterized by excessive movement in the vertebral column. While it can be asymptomatic, it often leads to pain, instability, and increased injury risk due to compromised spinal stability. Effective management focuses on enhancing the active and neural control subsystems through targeted strength, motor control, and proprioceptive training, rather than increasing flexibility. A clear understanding of the condition and a guided, individualized exercise program are crucial for individuals to manage their symptoms, improve function, and maintain a healthy, active lifestyle. Always consult with a qualified healthcare professional for an accurate diagnosis and personalized treatment plan.